Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults - Guideline for Antimicrobial Prophylaxis

Publication: 14/08/2009  --
Last review: 18/03/2022  
Next review: 18/03/2025  
Clinical Guideline
CURRENT 
ID: 1761 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis in Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS

See intra-operative re-dosing guidance below for operations lasting 3 or more hours.

Table 1: ACUTE/EMERGENCY

Note: Dosing in patients on antibiotic treatment pre-operatively

See appendix 1 for dosing and re-dosing summary.

Procedure

Antimicrobial dose/route
Give ≤1 hour before procedure

Routine

MRSA Colonised1 or penicillin allergy

Colonised by a coliform2 (e.g., E.coli) resistant to cefuroxime or ciprofloxacin or an ESBL, AMPC or CPE

Appendicectomy
Open or laparoscopic

Follow Appendicitis treatment guideline

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV plus Appendicitis treatment guideline

Discuss with microbiology5 as early as possible before surgery.

Biliary

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Colorectal surgery via laparotomy/ laparoscopic surgery.

Includes small and large bowel surgery.

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Hernia repair

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Liver

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Oesophageal

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Splenectomy
See: LTHT Guideline for infection prevention post splenectomy

NOT recommended except in immunosuppressed patients.7

NOT recommended except in immunosuppressed patients.7

Discuss with microbiology4 as early as possible before surgery.

Stomach & duodenal

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole500mg IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

 

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Table 2: ELECTIVE

Procedure

Antimicrobial dose/route
Give ≤1 hour before procedure

Routine

MRSA Colonised1 or penicillin allergy

Colonised by a coliform2 (e.g., E.coli) resistant to cefuroxime or ciprofloxacin or an ESBL, AMPC or CPE

Appendicectomy
Open or laparoscopic

Follow Appendicitis treatment guideline

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV plus Appendicitis treatment guideline

Discuss with microbiology5 as early as possible before surgery.

Bile duct surgery
(not gall bladder laparoscopic day case)

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4

Colorectal surgery via laparotomy/ laparoscopic surgery.

Includes small and large bowel surgery

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4

Endoscopic procedures: Diagnostic

Not recommended

Not recommended

Not applicable

Endoscopic procedures (ERCP & PEG): Therapeutic

See gastrointestinal endoscopy guideline

See gastrointestinal endoscopy guideline

 

Gall bladder (laparoscopic day case low risk)

Not recommended

Not recommended

Not applicable

Gastric bypass surgery

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Hernia repair

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Liver surgery (excluding transplant)

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on MetronidazoleIV 500mg

Discuss with microbiology4 as early as possible before surgery.

Oesophageal

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Pancreatic surgery

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology5 as early as possible before surgery.

Splenectomy
See: LTHT Guideline for infection prevention post splenectomy

NOT recommended except in immunosuppressed patients.6

NOT recommended except in immunosuppressed patients.6

Discuss with microbiology4 as early as possible before surgery.

Stomach & duodenal surgery (excluding gastric bypass)

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 grams IV and Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV

Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Discuss with microbiology4 as early as possible before surgery.

Surgery with prosthesis (e.g., gastric band or rectopexy)

NOT recommended except in high risk patients5/6

NOT recommended except in high risk patients5/6

 
  1. MRSA risk = previous MRSA infection or known colonisation
  2. Coliforms include E.coli, Enterobacter, Klebsiella, Serratia, Citrobacter and proteus.
  3. Teicoplanin takes 15 minutes to reconstitute
  4. Antibiotic choice will consider which antibiotics resistance has been detected to detected, the type of resistance, the timing the resistance was detected, recent antibiotic use (which may have selected out resistance), an individual’s risk of infection and the consequence of infection.
  5. High risk - conversion to laparotomy, pregnancy, immunosuppression, insertion of prosthetic devices.
  6. In immunosuppressed/high risk patients give: Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV or in MRSA Colonised or penicillin allergy give Teicoplanin electronic Medicines Compendium information on Teicoplanin3 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg

Redosing intra-operatively
Time based re-dosing
Every 3 hours redose Flucloxacillin, Every 4 hours redose Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav and Cefuroxime electronic Medicines Compendium information on Cefuroxime, Every 8 hours redose Metronidazole electronic Medicines Compendium information on Metronidazole, every 12 hours re-dose Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin. Do not give another dose of Teicoplanin

Blood loss based re-dosing
Re-dose if blood loss is estimated to exceed 1.5 Litres during surgery.

Note: If a surgeon attends a complex case for a particular procedure, they should be asked if there are additional antibiotic requirements.

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Appendix 1: Dosing and re-dosing summary.

Antibiotic prophylaxis choice

Procedure

Routine

MRSA Colonised or penicillin allergy

Biliary

Cefuroxime electronic Medicines Compendium information on Cefuroxime/Metronidazole electronic Medicines Compendium information on Metronidazole

 

Teicoplanin electronic Medicines Compendium information on Teicoplanin
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
Metronidazole electronic Medicines Compendium information on Metronidazole

Colorectal surgery

Cefuroxime electronic Medicines Compendium information on Cefuroxime/Metronidazole electronic Medicines Compendium information on Metronidazole

Hernia repair

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 

Liver

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav

Oesophageal

Cefuroxime electronic Medicines Compendium information on Cefuroxime/Metronidazole electronic Medicines Compendium information on Metronidazole

Stomach/ duodenal

Cefuroxime electronic Medicines Compendium information on Cefuroxime/Metronidazole electronic Medicines Compendium information on Metronidazole

 

Antibiotic dose and re-dosing in relation to time of surgery (time of incision)

Antibiotic received before theatre

Number of hours before surgery antibiotics given

To be given in theatre
(Antibiotic surgical prophylaxis)

< 1 hour before

Intra-operative re-dosing
Maximum 3 doses

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav

Given > 1 hour before

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV
(minimum dosing interval 60 minutes )

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV 4-hourly

Given < 1 hour before

 

From time of last dose:
Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV 4-hourly

Cefuroxime electronic Medicines Compendium information on Cefuroxime

Given > 1 hour before

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g IV
(minimum dosing interval 60 minutes)

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g IV 4-hourly

Given < 1 hour before

 

From time of last dose:
Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g IV 4-hourly

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Given > 1 hour before

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g IV
(minimum dosing interval 60 minutes ) 

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam
4.5g IV 4-hourly

Given < 1 hour before

 

From time of last dose:
Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam
4.5g IV 6-hourly

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

Given > 6 hour before

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV
 6-hourly

Given < 6 hour before

 

From time of last dose:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV
6-hourly

Metronidazole electronic Medicines Compendium information on Metronidazole

Given > 6 hour before

Metronidazole electronic Medicines Compendium information on Metronidazole500mg IV

Metronidazole electronic Medicines Compendium information on Metronidazole500mg IV
8-hourly

Given < 6 hour before

 

From time of last dose:
Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 
8-hourly

Teicoplanin electronic Medicines Compendium information on Teicoplanin

Given > 6 hours before

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV

From time of last dose:
Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV
12-hourly

Given < 6 hours before

 

From time of last dose:
Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV
12-hourly

Provenance

Record: 1761
Objective:
Clinical condition:

Gastrointestinal pathology

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

  • SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2014.
  • Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608.
  • Infection Control and Hospital Epidemiology November 2008, vol. 29, no. 11 Australian Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007
  • Fenton P et al. Journal Hospital Infection 68, (4), April 2008, Pages 376-37 Clostridium infection following hip surgery.
  • Kirby A, Asín-Prieto E, Burns FA, Ewin D, Fatania K, Kailavasan M, Nisar S, Pericleous A, Trocóniz IF, Burke D. Colo-Pro: a pilot randomised controlled trial to compare standard bolus-dosed cefuroxime prophylaxis to bolus-continuous infusion-dosed cefuroxime prophylaxis for the prevention of infections after colorectal surgery. Eur J Clin Microbiol Infect Dis. 2019 Feb;38(2):357-363.
  • Dubinsky-Pertzov B, Temkin E, Harbarth S, Fankhauser-Rodriguez C, Carevic B, Radovanovic I, Ris F, Kariv Y, Buchs NC, Schiffer E, Cohen Percia S, Nutman A, Fallach N, Klausner J, Carmeli Y; R-GNOSIS WP4 Study Group. Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae and the Risk of Surgical Site Infection After Colorectal Surgery: A Prospective Cohort Study. Clin Infect Dis. 2019 May 2;68(10):1699-1704.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 3.0

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